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Purpose Journal clubs are frequently used by healthcare educators to support learner’s critical thinking and clinical application. However, there is a lack of evidence to support the effectiveness of this learning tool for both the learner utilizing this tool and those in attendance. Debates have been proven to support critical thinking and communication skills. Method A journal club debate format and rubric were created to promote an engaging format for effective interpretation and application of drug information among fourth year pharmacy students and residents. Sections from relevant articles identified in a literature search were used to create a journal club debate format and rubric. This updated tool was used with pairs of pharmacy students and pharmacy residents. Feedback was obtained from the learners and the pharmacy preceptors in attendance. Results A journal club debate is generally well accepted by both learners and preceptors. Benefits include promotion of critical thinking, interpretation of evidence in the scope of supporting literature, and deeper understanding of the relevant disease state and treatment. Opportunities to improve may be the inclusion of limited visual aids for supporting evidence and the expansion of time for discussion and rebuttals. Conclusion Journal club debates are an engaging learning tool to promote and develop drug information identification, evaluation, and application to clinical practice among pharmacy students and residents.

Introduction: Ten thousand inter-hospital transfers of critically ill adults take place annually in the UK. Studies highlight deficiencies in experience and training of staff, equipment, stabilisation before departure, and logistical difficulties. This article is a quality improvement review of an advanced critical care practitioner (ACCP)-led inter-hospital transfer service. Methods: The tool Standards for Quality Improvement Reporting Excellence was used as the format for the review, combined with clinical audit of advanced critical care practitioner-led transfers over a period of more than 3 years. Results: The transfer service has operated for 8 years; ACCPs conducted 934 critical care transfers of mechanically ventilated patients, including 286 inter-hospital transfers, between January 2017 and September 2020. The acuity of transfer patients was high, 82.2% required support of more than one organ, 49% required more than 50% oxygen. Uneventful transfer occurred in 81.4% of cases; the most common patient-related complication being hypotension, logistical issues were responsible for half of the complications. Conclusion: This quality improvement project provides an example of safe and effective advanced practice in an area that is traditionally a medically led domain. ACCPs can provide an alternative process of care for critically ill adults who require external transfer, and a benchmark for audit and quality improvement.

Advanced critical care practitioners are a new and growing component of the critical care multidisciplinary team in the United Kingdom. This audit considers the safety profile of advanced critical care practitioners in the provision of central venous catheterisation and transfer of ventilated critical care patients without direct supervision and supervised drug assisted intubation of critically ill patients. The audit showed that advanced critical care practitioners can perform central venous cannulation, transfer of critically ill ventilated patients and intubation with parity to published UK literature.

PURPOSE: Assess systemic vascular endothelial growth factor-A (VEGF) levels after treatment with intravitreous aflibercept, bevacizumab or ranibizumab. DESIGN: Comparative-effectiveness trial with participants randomly assigned to 2-mg aflibercept, 1.25-mg bevacizumab, or 0.3-mg ranibizumab following a retreatment algorithm. PARTICIPANTS: Participants with available plasma samples (N=436) METHODS: Plasma samples were collected before injections at baseline, 4-week, 52-week and 104-week visits. In a pre-planned secondary analysis, systemic free-VEGF levels from an ELISA immunoassay were compared across anti-VEGF agents and correlated with systemic side effects. MAIN OUTCOME MEASURES: Changes in the natural log (ln) of plasma VEGF levels. RESULTS: Baseline free-VEGF levels were similar across all 3 groups. At 4 weeks, mean ln(VEGF) changes were −0.30±0.61, −0.31±0.54, −0.02±0.44 pg/ml for the aflibercept, bevacizumab, and ranibizumab groups, respectively. The adjusted differences between treatment groups (adjusted CI; P-value) were −0.01 (−0.12, +0.10; P=0.89), −0.31 (−0.44, −0.18; P

Background: CFDigiCare is a community of practice using digital adherence data, FEV1 and BMI to inform clinical decision-making and comprehensive digital behaviour change tools to support patient self-care. The 16 UK adult CF centres that form CFDigiCare work together using improvement science to embed digital data into routine care. The collaborative uses the Dartmouth Microsystems approach to build quality improvement (QI) capability Most CFDigiCare teams attended a one-day class-based QI training pre-COVID-19, with subsequent coaching delivered online. We discuss digital QI refresher training and coaching to the nationally dispersed improvement collaborative during the COVID crisis. Methods: 1-hour QI refresher training was delivered via MS Teams. Dartmouth improvement ramp activities were undertaken during subsequent 3 sessions. Results: Average attendance was 9. We explored two areas for improvement, teams participated in group ‘Fishbone’ exercises, silent brainstorming, discussed change ideas and planned PDSA cycles. Staff rated the meetings 9.4/10, commenting: • Useful QI demonstration and collaboration of ideas • Jamboard is a useful tool for gathering ideas • Can deliver it to the team • Good feedback for PDSAs Attendance was high with staff valuing practical interactive sessions using facilitated MS Teams calls and tools such as Google Jamboard. Virtual sessions connected clinicians from 16 centres providing a national “hive brain” perspective on system optimisation. The Dartmouth microsystems paradigm focused attention on specific aims, providing a structure to deliver iterative change. Virtual connectivity allowed QI to continue despite COVID-19. Familiarity with MS Teams increased over time with shared mastery of the technology a clear improvement outcome. Conclusion: Digital technology not only supports the delivery of QI training and coaching but can enhance it;clinical teams quickly mastered platforms such as MS Teams and Google Jamboard.

Sixty-one patients received a standardised anaesthetic and were randomly assigned to three groups: tracheal intubation via direct laryngoscopy, tracheal intubation via an intubating laryngeal mask airway with immediate removal of the device, and tracheal intubation via an intubating laryngeal mask airway with delayed removal. The cardiovascular response to intubation was of a similar magnitude in all groups, although delayed removal of the intubating laryngeal mask airway was associated with a second pressor response. Norepinephrine changed significantly over time following direct laryngoscopy and following immediate removal of the intubating laryngeal mask airway, but not after delayed removal. The findings of this study do not support using the intubating laryngeal mask instead of direct laryngoscopy purely to decrease the response to intubation.

To review the use of adjuncts to intravenous regional anesthesia (IVRA) for surgical procedures in terms of their intraoperative effects (efficacy of block and tourniquet pain) and postoperative analgesia.A systematic search (Medline, Embase, reference lists) for randomized, controlled and double-blinded studies using adjuncts to IVRA for surgical procedures was conducted. Data were collected on intraoperative effects (onset/offset and quality of block and tourniquet pain), postoperative effects (pain intensity and analgesic consumption) and side effects recorded. Statistical significance as indicated in the original report and likely clinical relevance were taken into account to arrive at a judgment of overall benefit.Twenty-nine studies met all inclusion criteria. Data on 1,217 study subjects are included. Adjuncts used were opioids (fentanyl, meperidine, morphine, sufentanil), tramadol, non-steroidal anti-inflammatory drugs (NSAIDs; ketorolac, tenoxicam, acetyl-salicylate), clonidine, muscle relaxants (atracurium, pancuronium, mivacurium), alkalinization with sodium bicarbonate, potassium and temperature. There is good evidence to recommend NSAIDs in general and ketorolac in particular, for improving postoperative analgesia. Clonidine 1 microg/kg also appears to improve postoperative analgesia and prolong tourniquet tolerance. Opioids are poor by this route; only meperidine 30 mg or more has substantial postoperative benefit but at the expense of postdeflation nausea, vomiting and dizziness. Muscle relaxants improve intraoperative motor block and aid fracture reduction.Using NSAIDs or clonidine as adjuncts to IVRA improves postoperative analgesia and muscle relaxant improves motor block.

OBJECTIVE: To establish a profile of sports hand injuries requiring treatment in an urban accident and emergency (A&E) department, and to determine the extent to which these injuries resulted in morbidity. METHODS: A one year prospective observational study at the Royal Victoria Infirmary, Newcastle upon Tyne. All patients presenting to the A&E department between 29 July 1995 and 28 July 1996 with a hand injury sustained during sporting activity and who received follow up by A&E or plastic surgery units were enrolled. Patients were contacted by telephone or post at median of four months after injury (range two to 13) for their assessment of the outcome. RESULTS: 262 cases were enrolled into the study. The median age for males was 21 years (range 7 to 55) and for females 16 (range 9 to 40). Follow up data were obtained by telephone in 206 (79%), and by letter in a further 26 (10%). Fractures were the commonest injury (68%), followed by soft tissue injuries (20%) and dislocations (11%). The thumb was the site affected most commonly overall, and in 10 of 17 ski related injuries; next most frequent sites were little and ring fingers. Males sustained 79% of the injuries, and 54% of these occurred during football. Netball/basketball caused 63% of female injuries. Follow up indicated that mild impairment in terms of pain, stiffness, or deformity was common (45%), while the incidence of moderate pain or serious problems was 11%. CONCLUSIONS: Sporting injuries to the hand commonly require treatment in the A&E department. Telephone/postal follow up of such injuries indicates that significant short term and longer term impairment of function may result. Suitable target areas for injury prevention are secondary schools, football (in males), and netball/basketball.

Purpose: To evaluate unfenestrated polysulfone intracomeal lenses (ICLs) in human sighted eyes 12 years after their implantation and to assess eyes that had the ICLs explanted. Setting: A department of clinical ophthalmology at a general hospital and the Department of Pathology at the National Institute of Ophthalmology, London, Great Britain. Methods: In this retrospective study, seven eyes were evaluated 12 to 14 years after ICL implantation. Case notes were scrutinized for preoperative ophthalmic history, and patients were interviewed and examined to establish outcome of the ICL implantation. Histopathological correlates were made for two study patients who had had ICL explantation and penetrating keratoplasty (PKP). Results: Uncorrected visual acuity in eyes retaining the ICL ranged between hand motion and 20/40, improving to 20/32 with correction. Corneal clarity varied between complete lucency to extensive opacity on each ICL surface. No corneal vascularization, endothelial decompensation, or uveitis was seen in eyes with clear ICLs. Acuity in eyes in which the ICL was explanted was between 20/20 corrected and finger counting in cases of PKP and between 20/200 and hand motion in eyes after lamellar keratoplasty. Conclusion: Despite satisfactory surgical technique in some eyes, unfenestrated polysulfone appears to be associated with color change and varying degree of stromal opacity in eyes evaluated 12 years postoperatively and thus cannot be considered clinically acceptable.

A three month prospective audit of wound infection following emergency and elective caesarean section was carried out in five West Yorkshire hospitals. Among 4076 women undergoing delivery in the five obstetric departments, the caesarean rate was 15.4%. The overall infection rate was 45/628 (7.2%) with a range of 2.5-17.2% between the five centres. The infection rate was 14/226 (6.2%) when antibiotics were used compared with 31/402 (7.7%) without antibiotics. The use of prophylactic antibiotics made no significant difference to the infection rate, which did not correlate with duration of labour or of ruptured membranes. The number of vaginal examinations correlated with the infection rate. In conclusion, the caesarean section rate observed was higher than that estimated for the UK as a whole, but was distorted by one centre with a high rate. For the other four hospitals the caesarean rate was unexceptional. The ratio of emergency to elective operations was comparable with recently reported values in the UK and the wound infection rate was within the widely varying limits found in previous studies. In view of the relatively low infection rate recorded without antibiotics, in the interests of cost effectiveness, prophylaxis may be limited in future to selected women at high risk. Because this was an audit rather than a randomized study we cannot exclude that this is already happening on an empirical basis.

Objectives: Accurate assessment of oxygen saturations (SaO2) is vital in the management of people with CF. Capillary blood gases (CBGs) are relatively painless and correlate well with arterial blood gases (ABGs) when estimating SaO2 in chronic lung disease [1]. Finger probe pulse oximetry (SpO2) is routinely used to estimate SaO2, but over the last 12 months we have started using ear probe pulse oximetry in our large regional CF centre. Our objective was to compare SaO2 by CBG or ABG with finger and ear probe SpO2 in adults with CF and normal controls. Methods:We performed simultaneous CBG or ABG, finger and ear probe SpO2 in adults with CF and normal controls. Finger and ear probe SpO2 were recorded by the same oximeter (Nonin Medical Inc.) using the appropriate sensors. Results: 21 sets of observations (19/21 CBGs) were recorded in 14 patients (6 male, mean age 29yrs, mean FEV1 30% predicted). 3 sets of observations (3/3 CBGs) were performed in 3 normal controls (1 male, mean age 31yrs). In patients ear probe SpO2 was significantly higher than finger probe SpO2 (*p < 0.001) and finger probe SpO2 was significantly lower than SaO2 (^p =0.01).

Seventy-five inexperienced participants were timed inserting the laryngeal mask airway (LMA) and the intubating laryngeal mask (ILM) in one of five cadavers. Adequacy of ventilation was assessed on a three-point scale depending on chest expansion and air leak. Participants were also asked to intubate the trachea via the ILM. The ILM was inserted faster than the LMA (P0.05) with a greater proportion achieving adequate ventilation after their first attempt (P0.05). Tracheal intubation via the ILM was completed successfully by 67% (52 of 75) of participants. In a questionnaire, participants stated that the ILM was easier to use and the preferred device in an emergency. The results suggest that inexperienced practitioners should use the ILM rather than the LMA for emergency ventilation.

Introduction and objectives People with cystic fibrosis (CF) are prone to airway infection with non-tuberculous mycobacteria (NTM) including M. abscessus , M. avium and M. intracellulare . Routine NTM screening is recommended for all patients at least once a year. 1 In patients not able to produce sputum, cough swabs are often sent for NTM analysis. Anecdotally, we observed that several patients cared for in our centre had cultured NTM in sputum having previously been culture-negative from cough swabs. The objective of this observational study was to examine the diagnostic yield of cough swabs and sputum samples from CF adults with known NTM infection. Methods We identified all CF patients being cared for in our large regional adult CF centre that had cultured any NTM species from cough swabs or sputum samples and are currently attending our NTM clinic. Demographics, clinical parameters and microbiology results were recorded and analysed. Results 26 patients (19 male) were included: median age 24 years, 92% chronically infected with P. aeruginosa , 100% pancreatic insufficient, 62% CF-related diabetes, 27% ABPA. 381 sputum samples and 55 cough swabs were analysed. 251 (66%) sputum samples and 4 (7%) cough swabs cultured NTM (see Table 1). In the 4 cough swabs that cultured NTM, sputum samples also cultured the same species. Conclusions Cough swabs have a very low diagnostic yield and their use did not contribute to identification of NTM infection in our adult CF patient population. We have therefore stopped sending cough swabs for NTM culture in our centre and our data suggests that cough swabs should not be used to screen for these organisms. Reference 1 Mycobacterium abscessus Suggestions for infection prevention and control. CF Trust, 2013

OBJECTIVE: To survey general practitioners' opinions of the quality of care offered by an urban accident and emergency (A&E) department. METHODS: A postal questionnaire was used. The questionnaire addressed issues of patient treatment, communications between hospital and GPs, and the GPs' perceptions of patient satisfaction. Questions required graded responses. Response rate was 57% (91 of 160 GPs mailed). RESULTS: 96% and 91% of responders respectively were satisfied with patient assessment and treatment, and 70% were satisfied with the explanation given to the patient. Problems were highlighted in communications between the department and GPs. 68% reported that adult patients always/usually gave their practice a hand written letter detailing their initial A&E attendance. Concerns were expressed about the content, illegibility, and inconvenience of this form. 42% of GPs reported never/rarely receiving a typed summary of patients discharged from the A&E review clinic. 28% of GPs would have appreciated a telephone call from the department on occasions. The areas of most patient dissatisfaction were perceived by GPs as: waiting time (67%), communication (19%), staff attitude (7%), and actual treatment (7%). CONCLUSIONS: A postal survey of local GPs can give valuable information about the quality of care provided by a hospital department. Overall GP satisfaction with the service was high, but there are concerns about aspects of written and telephone communications between the department and GPs, which can be addressed.

Background and Objectives To quantify the motor threshold current of a needle following elicitation of paresthesia during axillary brachial plexus block (ABPB). Methods This is a prospective, observational study of ABPB in 72 patients. Having elicited paresthesia, the minimum current required to produce a motor response was noted. The development and success of the block were subsequently followed. Results Nineteen blocks were excluded (18 because of arterial puncture and 1 blocked needle). Of the remaining 53 blocks, 41 (77%) produced a motor response at 0.5 mA or less. The median current was 0.17 mA (range, 0.03 to 3.3 mA). The site of initial paresthesia and subsequent motor response were related in 43 (81%) of cases. Conclusions A needle position causing paresthesia produced a motor response at 0.5 mA or less in 77% of cases studied. This current may, therefore, be a reasonable threshold to aim for when performing an ABPB.

STUDY OBJECTIVE--The aim of the study was to investigate the accuracy of one year's cervical cancer registrations and to review these women's medical records. DESIGN--The study was a survey of medical records of women registered as having a malignancy of cervix or uterus in 1985. SETTING--Cases were drawn solely from the county of Leicestershire, having been registered by the Trent Cancer Registration Bureau. PATIENTS--The study group comprised all 82 women registered as having a malignancy of cervix or uterus (part unspecified) during the study period. In one case the medical records could not be obtained, so 81 were reviewed. MEASUREMENTS AND RESULTS--Medical records were reviewed; demographic, clinical and tumour characteristics, and screening experience were noted. Errors of registration of invasive cancer resulted in a 22% overestimate: only 54 of 66 cases registered actually had this cancer. Cases over 40 years of age (n = 37) were compared to those under 40 (n = 17). Thirty two women (59%), predominantly in the older age group, had never had a cervical smear. Forty four women (81%) presented with symptoms rather than as a result of screening. There was no difference in the stage of the disease at presentation between the two age groups but eight of nine women under 35 years had poorly differentiated tumours. At 2 year follow up, 12 (71%) of the younger women were alive and asymptomatic, one had a recurrence and four were dead. The corresponding figures for the older women were 18 (50%), 5 (14%) and 13 (36%). Eight screened women had only had normal smears reported in the 5 years preceding the cancer diagnosis. Seven of these were under 45 years old and four had late stage disease. CONCLUSIONS--It will be impossible to assess the impact of newly implemented computerised call and recall systems for cervical cytology screening unless a more reliable data base can be created.

The reasons for and appropriateness of referral of patients after initial visit to accident & emergency (A&E) follow-up clinics by the A&E doctors were prospectively analysed in 500 patients. Fifteen per cent of patients were judged to have been inappropriately referred. Two main reasons for referral were the need for further treatment and uncertainty about diagnosis and management. The implications of reductions of A&E clinic attendances are discussed.

A 60-year-old woman was referred to the Plastic Surgery outpatients with a %-week history of a lump in the right side of her neck. This was uncomfortable, but there were no other specific symptoms at presentation. She was taking carbimazole for thyrotoxicosis and digoxin for atria1 fibrillation. In 1967, she had undergone surgery to remove a pleomorphic adenoma from an accessory lobe of her right parotid gland. She did not have sialography or any further treatment for this condition. Physical examination confirmed a hard mass in the right side of the neck below and behind the angle of the mandible, fixed to the sternocleidomastoid. There was no lymphadenopathy. The clinical diagnosis was of a neoplasm arising in the lower pole of the parotid gland. Fine needle aspiration showed necrotic tissue with inflammatory cells, but no evidence of malignancy. Magnetic Resonance Imaging showed fatty change in the upper pole of the parotid. An ill-defined, lobulated mass involved the inferior part of the superficial and deep lobes, with characteristics typical of an infiltrating malignancy (Fig. lA, B). Ultrasound with Doppler examination confirmed these appearances, demonstrating vascular changes consistent with a neoplastic circulation. At surgery, the mass seemed to invade the sternocleidomastoid. The patient, therefore, underwent a total parotidectomy, sparing the facial nerve, and a radical neck dissection. She has since made an uneventful recovery with no facial palsy. The resected specimen is unique. On sectioning, the mass was centrally yellow and friable; grey and more fibrous peripherally. It had spread into the adjacent muscle and two discrete jugular lymph nodes had further separate deposits. Histology showed a highly cellular granulomatous inflammatory process with numerous foamy and fat

EDITOR,—We agree with the main thrust of Yvonne Stedman and Max Elstein's editorial advocating more cohesive provision of sexual health services.1 But have the authors taken too narrow a view of where and when patients present? There is no mention of the work of accident and emergency departments in this field. Males who present to accident and emergency departments with problems of a sexual nature can usually be managed with either reassurance or referral for investigation in the relevant clinic, …

EDITOR, - Giles Tremlett's news item on a Russian eye hospital ship operating in the area of Gibraltar1 suggests that ophthalmology is in danger of confusing two issues that should be kept apart. The first issue concerns the legality of a foreign registered floating eye hospital operating in British-Spanish territorial waters, presumably without any attempt having been made to obtain a licence for the doctors on board from the relevant professional body: …

EDITOR,—In vitro fertilisation and similar reproductive techniques are now capable of producing dangerously large numbers of fertilised human eggs, as shown by the woman who was expecting octuplets recently.1 But …

Since 1963, the Choyce Mark VIII lens, a quadrupedal, anterior chamber implant, has proved satisfactory following conventional intracapsular surgery in eyes of normal size, but less successful after primary extracapsular procedures and in small eyes. Reducing some of its dimensions by as much as 30'70 enables the surgeon to treat a much wider range of cataract problems through a smaller incision. The reduced-size version is known as the Choyce Mark IX anterior chamber implant. The quadrupeda l principle has been preserved.

The author only started primary Mark VIII implantation in 1970, and has only a modest total of 50 cases at this time. Therefore it is premature to draw too many conclusions when comparing this small series with secondary implantation going back over 20 years and covering approximately 1200 years. However the following tentative conclusions are drawn: 1. When confronted with pre-existing aphakia (particularly unilateral) the visual and psychological results of secondary Mark VIII implantation are excellent over a wide spectrum of indications and ocular states. It is a very adaptable and versatile implant--a true "Implant for all Seasons" as Clayman has said. 2. Primary Mark VIII implantation shows considerable promise, particularly when allied to a well-thought-out and carefully-executed microsurgical technique as devised by Tennant. The author is performing more and more primary implantations and regards second eyes as a very favorable indication.